E-Learning Center : Program Information : Programs : Terre Haute Boys & Girls Club

Child's Name

First Name *

Last Name *

Grade Fall 2020 (Required)

School Fall 2020 (Required)

Age (Required)

Gender (Required)

Parent/Guardian

First Name *

Last Name *

Parent/Guardian Mobile Phone (Required)

Parent/Guardian Work Phone (Required)

Parent/Guardian Email (Required)

Day/Week Registering For (Required)

Medical Condition (Required)

Please explain Medical Condition

Electronic Signature of Parent or Guardian (Required)

Date

Email Address for Confirmation of Submission (Required)

Online Clubhouse Program Cost

$10.00 per day. Choose box that applies to number of days your are registering for.

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Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged